Peptic Ulcer Disease in Children

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Chapter 327 Peptic Ulcer Disease in Children

Peptic ulcer disease, the end result of inflammation due to an imbalance between cytoprotective and cytotoxic factors in the stomach and duodenum, manifests with varying degrees of gastritis or frank ulceration. The pathogenesis of peptic ulcer disease is multifactorial, but the final common pathway for the development of ulcers is the action of acid and pepsin-laden contents of the stomach on the gastric and duodenal mucosa and the inability of mucosal defense mechanisms to allay those effects. Abnormalities in the gastric and duodenal mucosa can be visualized on endoscopy, with or without histologic changes. Deep mucosal lesions that disrupt the muscularis mucosa of the gastric or duodenal wall define peptic ulcers. Gastric ulcers are generally located on the lesser curvature of the stomach, and 90% of duodenal ulcers are found in the duodenal bulb. Despite the lack of large population-based pediatric studies, rates of peptic ulcer disease in childhood appear to be low. Large pediatric centers anecdotally report an incidence of 5-7 children with gastric or duodenal ulcers per 2,500 hospital admissions each year.

Ulcers in children can be classified as primary peptic ulcers, which are chronic and more often duodenal, or secondary, which are usually more acute in onset and are more often gastric (Table 327-1). Primary ulcers are most often associated with Helicobacter pylori infection; idiopathic primary peptic ulcers account for up to 20% of duodenal ulcers in children. Secondary peptic ulcers can result from stress due to sepsis, shock, or an intracranial lesion (Cushing ulcer) or in response to a severe burn injury (Curling ulcer). Secondary ulcers are often the result of using aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs); hypersecretory states like Zollinger-Ellison syndrome (Chapter 327.1), short bowel syndrome, and systemic mastocytosis are rare causes of peptic ulceration.

Pathogenesis

Clinical Manifestations

The presenting symptoms of peptic ulcer disease vary with the age of the patient. Hematemesis or melena is reported in up to half of the patients with peptic ulcer disease. School-aged children and adolescents more commonly present with epigastric pain and nausea, presentations generally seen in adults. Dyspepsia, epigastric abdominal pain or fullness, is seen in older children. Infants and younger children usually present with feeding difficulty, vomiting, crying episodes, hematemesis, or melena. In the neonatal period, gastric perforation can be the initial presentation.

The classic symptom of peptic ulceration, epigastric pain alleviated by the ingestion of food, is present only in a minority of children. Many pediatric patients present with poorly localized abdominal pain, which may be periumbilical. The vast majority of patients with periumbilical or epigastric pain or discomfort do not have a peptic ulcer, but rather a functional GI disorder, such as irritable bowel syndrome or nonulcer (functional) dyspepsia. Patients with peptic ulceration rarely present with acute abdominal pain from perforation or symptoms and signs of pancreatitis from a posterior penetrating ulcer. Occasionally, bright red blood per rectum may be seen if the rate of bleeding is brisk and the intestinal transit time is short. Vomiting can be a sign of gastric outlet obstruction.

The pain is often described as dull or aching, rather than sharp or burning, as in adults. It can last from minutes to hours; patients have frequent exacerbations and remissions lasting from weeks to months. Nocturnal pain waking the child is common in older children. A history of typical ulcer pain with prompt relief after taking antacids is found in <33% of children. Rarely, in patients with acute or chronic blood loss, penetration of the ulcer into the abdominal cavity or adjacent organs produces shock, anemia, peritonitis, or pancreatitis. If inflammation and edema are extensive, acute or chronic gastric outlet obstruction can occur.

Primary Ulcers

Helicobacter Pylori Gastritis

H. pylori is among the most common bacterial infections in humans. H. pylori is a gram-negative, S-shaped rod that produces urease, catalase, and oxidase, which might play a role in the pathogenesis of peptic ulcer disease. The mechanism of acquisition and transmission of H. pylori is unclear, although the most likely mode of transmission is fecal-oral or oral-oral. Viable H. pylori organisms can be cultured from the stool or vomitus of infected patients. Risk factors such as low socioeconomic status in childhood or affected family members also influence the prevalence. All children infected with H. pylori develop histologic chronic active gastritis but are often asymptomatic. In children, H. pylori infection can manifest with abdominal pain or vomiting and, less often, refractory iron deficiency anemia or growth retardation. H. pylori can be associated, though rarely, with chronic autoimmune thrombocytopenia. Chronic colonization with H. pylori can predispose children to a significantly increased risk of developing a duodenal ulcer, gastric cancer such as adenocarcinoma, or MALT (mucosa-associated lymphoid tissue) lymphomas. The relative risk of gastric carcinoma is 2.3-8.7 times greater in infected adults as compared to uninfected subjects. H. pylori is classified by the World Health Organization as a group I carcinogen.

Anemia, idiopathic thrombocytopenic purpura, short stature, and sudden infant death syndrome (SIDS) have also been reported as extragastric manifestations of H. pylori infection. In one published study, H. pylori infection has been correlated with cases of SIDS, but there is no evidence to suggest that H. pylori plays a role in the pathogenesis of SIDS.

The diagnosis of H. pylori infection is made histologically by demonstrating the organism in the biopsy specimens (Fig. 327-1). Although serologic assays using validated immunoglobulin G (IgG) antibody detection may be helpful for screening children for the presence of H. pylori, they do not help predict active infection or assess the success of antimicrobial eradication therapy. 13C-urea breath tests and stool antigen tests are also noninvasive methods of detecting H. pylori infection. Nonetheless, for children with suspected H. pylori infection, an initial upper endoscopy is recommended to evaluate and confirm H. pylori disease. The range of endoscopic findings in children with H. pylori infection varies from being grossly normal to the presence of nonspecific gastritis with prominent rugal folds, nodularity (Fig. 327-2), or ulcers. Because the antral mucosa appears to be endoscopically normal in a significant number of children with primary H. pylori gastritis, gastric biopsies should always be obtained from the body and antrum of the stomach regardless of the endoscopic appearance. If H. pylori is identified, even in a child with no symptoms, eradication therapy should be offered (Tables 327-2 and 327-3).

image

Figure 327-1 Appearance of Helicobacter pylori on the gastric mucosal surface with Giemsa stain (high-power view).

(From Campbell DI, Thomas JE: Heliobacter pylori infection in paediatric practice, Arch Dis Child Edu Pract Ed 90:ep25–ep30, 2005.)

image

Figure 327-2 Endoscopic view of lymphoid modular hyperplasia of the gastric antrum.

(From Campbell DI, Thomas JE: Heliobacter pylori infection in paediatric practice, Arch Dis Child Edu Pract Ed 90:ep25–ep30, 2005.)

Table 327-2 RECOMMENDED ERADICATION THERAPIES FOR H. PYLORI–ASSOCIATED DISEASE IN CHILDREN

MEDICATIONS DOSE DURATION OF TREATMENT
Amoxicillin 50 mg/kg/day in 2 divided doses 14 days
Clarithromycin 15 mg/kg/day in 2 divided doses 14 days
Proton pump inhibitor 1 mg/kg/day in 2 divided doses 1 mo
or
Amoxicillin 50 mg/kg/day in 2 divided doses 14 days
Metronidazole 20 mg/kg/day in 2 divided doses 14 days
Proton pump inhibitor 1 mg/kg/day in 2 divided doses 1 mo
or
Clarithromycin 15 mg/kg/day in 2 divided doses 14 days
Metronidazole 20 mg/kg/day in 2 divided doses 14 days
Proton pump inhibitor 1 mg/kg/day in 2 divided doses 1 mo

Adapted from Gold BD, Colletti RB, Abbott M, et al: Medical position statement: The North American Society for Pediatric Gastroenterology and Nutrition. Helicobacter pylori infection in children: recommendations for diagnosis and treatment, J Pediatr Gastroenterol Nutr 31:490–497, 2000.

Table 327-3 ANTISECRETORY THERAPY WITH PEDIATRIC DOSAGES

MEDICATION PEDIATRIC DOSE HOW SUPPLIED
H2 RECEPTOR ANTAGONISTS
Cimetidine 20-40 mg/kg/day
Divided 2 to 4 × a day
Syrup: 300 mg/mL
Tablets: 200, 300, 400, 800 mg
Ranitidine 4-10 mg/kg/day
Divided 2 or 3 × a day
Syrup: 75 mg/5 mL
Tablets: 75, 150, 300 mg
Famotidine 1-2 mg/kg/day
Divided twice a day
Syrup: 40 mg/5 mL
Tablets: 20, 40 mg
Nizatidine 10 mg/kg/day
Divided twice a day
 
PROTON PUMP INHIBITORS
Omeprazole 1.0-3.3 mg/kg/day
<20 kg: 10 mg/day
>20 kg: 20 mg/day
Approved for use in those >2 yr old
Capsules: 10, 20, 40 mg
Lansoprazole 0.8-4 mg/kg/day
<30 kg: 15 mg/day
>30 kg: 30 mg/day
Approved for use in those >1 yr old
Capsules: 15, 30 mg
Powder packet: 15, 30 mg
Solu-tab: 15, 30 mg
Rabeprazole Adult dose: 20 mg/day Tablet: 20 mg
Pantoprazole Adult dose: 40 mg/day Tablet: 40 mg
CYTOPROTECTIVE AGENTS
Sucralfate 40-80 mg/kg/day Suspension: 1,000 mg/5 mL
Tablet: 1,000 mg

Treatment

The management of acute hemorrhage includes serial monitoring of pulse, blood pressure, and hematocrit to insure hemodynamic stability and avoid significant anemia. Normal saline can be used to resuscitate a patient who has poor intravascular volume status. This can be followed by packed red blood cell transfusions for significant symptomatic anemia. The patient’s blood should be typed and cross matched, and a large-bore catheter should be placed for fluid or blood replacement. A nasogastric tube should be placed to determine if the bleeding has stopped. Significant anemia can occur after fluid resuscitation due to equilibration or continued blood loss (which can also cause shock). Fortunately, most acute peptic ulcer bleeding stops spontaneously.

Patients with suspected peptic ulcer hemorrhage should receive high-dose intravenous PPI therapy, which lowers the risk of rebleeding. Some centers also use octreotide, which lowers splanchnic blood flow and gastric acid production.

Once the patient is hemodynamically stable, endoscopy may be indicated to identify the source of bleeding and treat a potential bleeding site. Methods used for vessel hemostasis include pressure, laser, thermal, or electric coagulation; clips; bands; and injections (epinephrine, saline).

Ulcer therapy has two goals: ulcer healing and elimination of the primary cause. Other important considerations are relief of symptoms and prevention of complications. The first-line drugs for the treatment of gastritis and peptic ulcer disease in children are H2 receptor antagonists and PPIs (see Table 327-3). PPIs are more potent in ulcer healing. Cytoprotective agents can also be used as adjunct therapy if mucosal lesions are present. Antibiotics in combination with a PPI must be used for the treatment of H. pylori-associated ulcers (see Table 327-2).

H2 receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine) competitively inhibit the binding of histamine at the H2 subtype receptor of the gastric parietal cell. PPIs block the gastric parietal cell H+/K+ATPase pump in a dose-dependent fashion, reducing basal and stimulated gastric acid secretion. At least 5 PPIs are available in the United States: omeprazole, lansoprazole, pantoprazole, esomeprazole, and rabeprazole. Although not all of them are approved for use in children, they are well tolerated with only minor adverse effects, such as diarrhea (1-4%), headache (1-3%), and nausea (1%). When one considers therapeutic efficacy, the evidence suggests that all PPIs have comparable efficacy in treatment of peptic ulcer disease using standard doses and are superior to H2-receptor antagonists. PPIs have their greatest effect when given before a meal.

Treatment of H. Pylori–Related Peptic Ulcer Disease

In pediatrics, antibiotics and bismuth salts have been used in combination with PPIs to treat H. pylori infection (see Table 327-2). Eradication rates in children range from 68% to 92% when the dual or triple therapy is used for 4-6 wk. The ulcer healing rate ranges from 91% to 100%. Triple therapy yields a higher cure rate than dual therapy. The optimal regimen for the eradication of H. pylori infection in children has yet to be established, but the use of a PPI in combination with clarithromycin and amoxicillin or metronidazole for 2 wk is a well-tolerated and recommended triple therapy (see Table 327-2). Although children <5 yr of age can become reinfected, the most common reason for treatment failure is poor compliance or antibiotic resistance. H. pylori has become more resistant to clarithromycin or metronidazole due to the extensive use of these antibiotics for other infections. In the case of resistant H. pylori infection, sequential treatment or rescue therapy with different antibiotics is acceptable options. The sequential treatment regimen is a 10-day treatment consisting of a PPI and amoxicillin (both twice daily) administered for the first 5 days followed by triple therapy consisting of a PPI, clarithromycin, and metronidazole for the remaining 5 days. Levofloxacin, rifabutin, or furazolidone can be used with amoxicillin and bismuth as a rescue therapy depending on the age of the patient. Fidaxomicin has equivalent efficacy to vancomycin in adults. Knowledge of the community’s H. pylori resistance pattern to clarithromycin or metronidazole might help chose the initial or rescue therapy.

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